12 October 2017
It is the medical problem that no-one wants to admit to having.
The ‘butt’ of so many jokes, haemorrhoids – commonly known as piles – appear to be at the bottom of the list when it comes to ailments people want to discuss with their GP!
However, ignoring them – or simply rubbing on some cream bought over the counter at your local chemist – is not the way to react, according to Consultant Colorectal Surgeon, Mr David McArthur.
“But even worse, what you think are haemorrhoids could be something much worse – including cancers of the anus or bowel. It really is a good idea to get them checked out by an expert – sometimes a more detailed investigation than one that can be carried out by your GP is needed to identify the real problem.”
Here Mr McArthur answers some of the most commonly asked questions when it comes to haemorrhoids.
1. What are piles?
Piles, or haemorrhoids, are dilated anal cushions, pieces of very veiny tissue just inside the anal canal that have a normal role in preserving continence by acting like a stopper to prevent the passage of flatus (gas) or liquid or solid motion.
Over time, these anal cushions can become detached from the anal muscle lining and descend down through the anal canal, at which point they are known as ‘piles’.
Piles are classified according to how much they protrude, or prolapse, through the anal canal:
- Grade 1 are always inside the anal canal
- Grade 2 prolapse on defecation but go back up spontaneously
- Grade 3 prolapse on defaecation and need to be pushed back manually
- Grade 4 are always prolapsed.
They can cause a variety of symptoms, including rectal bleeding, anal discomfort, itching (also known as pruritis), a sensation of fullness of the bowel, passage of mucous and problems with cleanliness.
Most people who have anal symptoms, no matter what the cause, attribute them to piles as they are so common. But there are numerous other anal conditions, some of which can be serious, that mimic piles and so can be confused for such.
2. How do you get them?
They are very common; most people at some stage will get piles to some degree. However, certain situations make it more likely that they will arise, or continue to give problems once they have developed.
The main cause is constipation and straining to pass hard stools. They are also common during and soon after pregnancy due to increased pressure in the pelvis. Other conditions might underlie piles developing, such as liver disease causing back pressure on the veins in the haemorrhoidal tissue, or connective tissue disorders.
3. Do they affect a particular sex or age group?
Piles tend to affect people as they become older, when the normal collagen and connective tissues become weaker, hence allowing the anal cushion tissue to become detached from the underlying muscle and become a pile. However, younger people are often also affected if they are constipated and strain to pass stools, or in women when they are pregnant. Essentially anyone can be affected.
4. Are they treatable?
Yes, piles are eminently treatable. The first step to treatment however is assessment to make sure that the symptoms the patient is experiencing are definitely due to piles.
5. If so, what sort of treatments are available?
The most basic, and often most effective treatment, are simple lifestyle changes to reduce constipation. Eating a high fibre diet and drinking more fluid (two to three litres per day) can often result in stools that are easier to pass, hence reducing the need to strain, causing piles to regress and get smaller.
If these measures are not enough to prevent constipation and straining, taking a simple stool softening laxative, such as lactulose or movicol, can also help.
Even if piles require more advanced forms of treatment, addressing constipation through these measures is important to prevent them from recurring after treatment.
Patients often use over-the-counter creams, which offer symptomatic treatment but rarely result in the piles disappearing in a manner that wouldn’t just occur naturally.
If simple measures don’t work there are a number of surgical treatments available. These range from procedures that can be performed in the out patient department to operations performed with the patient under general anaesthetic:
- Banding of piles involves the application of rubber bands on the base of the pile, causing a scarring process and causing it to shrink.
- Injection sclerotherapy works in the same manner as banding. Both banding and injection can be done in out-patient clinic.
- THD (Trans-anal Haemorrhoidal Dearterialisation), or HALO (Haemorrhoidal Artery Ligation), are procedures done with the patient under general anaesthetic. They involve the use of a Doppler probe to identify the artery that supplies the pile tissue, which is then stitched to prevent the blood supply to that tissue. This results in the shrinking of the pile. The haemorrhoidal tissue is often also stitched up inside the anal canal.
- Haemorrhoidectomy is the surgical excision of the pile tissue. It is a very effective treatment, but is also generally very painful.
- Newer procedures, such as Rafaello (Radiofrequency treatment), are under development and in the early stages of being offered to patients with piles.
These treatments can vary in effectiveness depending on the grade of the piles. No one treatment is perfect for all patients so seeing a specialist who can offer a number of options is important.
6. What can happen if you decide to put up with the effects and avoid treatment?
Essentially nothing! Often, once people know their symptoms are down to piles and not something more sinister, they decide to manage things with dietary modifications and lifestyle changes.
A surgeon should never tell you that “you must have your piles treated” - rather they should give you all the options that might be effective to treat the condition.
Occasionally, if piles are left untreated and get bigger, complications can arise. The main thing that can happen is the pile tissue, if it is protruding through the anal canal, can become very engorged with blood which increases the pressure in the tissue and then prevents further fresh arterial blood entering the tissue.
This is a condition known as a thrombosed pile. It can be very painful and sometimes presents as a surgical emergency. However, this is rare when you consider the proportion of people who have piles.
7. What other problems could haemorrhoids be hiding?
It is commonly the case that any symptoms from the anal canal and lower bowel are attributed to piles by both patients and GPs. However, whilst common, this is not always the case.
The most common conditions confused for haemorrhoids are:
- Anal skin tags. These pieces of skin that protrude at the anal verge are often the consequence of piles that have been bigger in the past, but have subsequently regressed inside the anal canal, leaving some redundant skin (much in the same way as people who lose a lot of weight can be left with redundant skin).
- Anal fissures, which are tears inside the anal canal that result in pain and bleeding.
- Anal fistulas, communications between the inside of the anal canal and outside skin that often occur after an anal abscess.
- Anal warts.
However, other more serious conditions can present with similar symptoms to piles, including:
- Inflammatory bowel conditions such as Crohn’s disease or ulcerative colitis.
- Anal cancer.
- Rectal cancer.
For this reason, anyone with anal symptoms should be properly examined to ensure they are due to piles and not something that would require further evaluation or treatment.
8. How would a specialist check differ from a GP examination?
Often GPs can perform an adequate examination to diagnose piles and, more importantly, rule out other more serious conditions.
However, due to time constraints in their clinics and sometimes a lack of experience, it is not uncommon that patients are not properly examined so seeing a specialist who deals with piles and other anal conditions on a daily basis is advisable.
All patients should have a rectal examination performed by someone experienced in this, and preferably a proctoscopy (short plastic tube inserted into the anal canal to visualise piles or other conditions). Often patients will also require a more detailed examination of the bowel with a flexible camera (sigmoidoscopy or colonoscopy).
9. How vital can an early check be – particularly in recognising other possible problems?
Establishing an accurate diagnosis early on, when patients first notice symptoms is key. Unfortunately, as a Colorectal Surgeon I do see some people who have had their anal symptoms treated for many months as piles when, in fact, the underlying cause is a low rectal or anal cancer. If there is any doubt, get checked out by an expert!
Not only is there a tendency for all anal symptoms to be attributed to piles but people are understandably embarrassed by their symptoms and therefore reluctant to seek medical attention. However, they shouldn’t be embarrassed – getting checked out early could be very important.
10. Even if it is haemorrhoids and not something more sinister, can ignoring them or merely applying cream lead to more problems in the future?
As mentioned before, this is rarely the case. The key is to not ignore the symptoms. Find someone who can reach an accurate diagnosis and then decide with a specialist how best to manage the symptoms.
The content of this article is provided for general information only, and should not be treated as a substitute for the professional medical advice of your doctor or other health care professional.